By Dr. James M. Dahle, WCI Founder
Every year my partnership has an annual retreat. We hear from our 401(k) guy (who amusingly always tries to predict the future), we get to compare ourselves to how the other divisions within the partnership are doing financially, we get to learn a little bit about risk management, and we get to hear about the threats to our business from publicly-traded, predatory corporations in Emergency Medicine like EMCare and TeamHealth who are constantly trying to steal contracts from small democratic groups. But we also usually bring in a paid keynote speaker. This year's speaker was Dike Drummond, AKA The Happy MD, author of Stop Physician Burnout.
The Unhappy MD
Actually, Dike wasn't a very happy MD, and in fact, no longer practices medicine at all because he burned out of Family Practice at 40. He now does coaching to individual MDs as well as groups of MDs in order to help them avoid burnout and to treat burnout. Apparently, that's about when most people burnout, around age 40, after about 40,000 patient visits. He think that is because at that point in your career you are seeing very few conditions and presentations for the first time, so your job becomes much more routine. You're now building widgets on the assembly line I guess rather than having a profound intellectual experience.
Dike Drummond, MD
I think there is some wisdom there. I loved residency, even though it was definitely a brutal job. But everything was so new and cool all the time it was worth putting up with the terrible hours, constant variation, odd attendings, and stress. The worst part about docs burning out at 40 is that is when they are most competent. In fact, if you survey patients, they want their doctors to be 40. That puts them far enough out of their training that they're competent, but not so far out that they're not up to date on the latest stuff. What I've personally noted about 40 is that it is becoming very rare for a patient to ask me if I'm old enough to be their doc anymore, a question I used to get multiple times a day. I don't tell them I'm rapidly approaching financial independence/retirement.
But Dike does a great 90 minute training session for docs and their spouses over dinner and drinks. I was able to corner him earlier that afternoon to talk business with him. I was impressed with how he runs his speaking/training gigs, and he was impressed with how many of you come by this site.
More Ways to Fight Burnout
Prior to Dike's presentation, my approach to burnout has been primarily financial. I figured that if a doc took care of her finances, she would be financially free to do whatever she wanted in her practice. If she wants to take longer with patients, she can afford to do that. If she wants to work shorter hours or fewer days she can do that. If she wants to drop nights or call or whatever, as long as the finances allow, great! However, that approach doesn't work for everybody, and it certainly doesn't work quickly for anyone. Dike provides all kinds of ideas about how to decrease burnout WITHOUT dropping your income significantly. (Although he told me that he has helped five doctors retire. They were burned out and didn't realize they already had “enough.”)
Boundaries
There were two particularly good ideas I took home from the presentation. The first is to establish boundaries between your work and your home life, and to actually have a boundary ritual between them. (Think Mr. Rogers changing his shoes at the start of the show.) As an emergency doc, the boundary between work and home has always been pretty easy for me. I sign-out my patients, hang up my stethoscope, and walk out the door. I'm Me again, and no longer Me, MD. I'm never on call and rarely see the same patient twice. However, the boundary I struggle with is the boundary between Me and WCI. As my wife will tell you, sometimes I'm home but not really home. As you might imagine, an enterprise like this has a way of expanding to fill all available time. So I'm working on coming up with a good way to draw boundaries around WCI to allow me to do things that I also enjoy.
The Ideal Life
The second good idea is to use a Venn Diagram to improve your practice and/or your life. Basically, the circle on the left is your ideal practice/life. The circle on the right is your current practice/life.
The amount of overlap determines how happy you are. Drummond says if the overlap is 60% or more, you are likely very happy and unlikely to burn out. If it is 20% or less, watch out! You are very likely to burn out very soon. I felt pretty good about that, since just before he gave out those guidelines, I leaned over and told my wife I had 60-80% overlap. Once I cut my shifts back a little bit next summer and drop my night shifts, I figure my practice Venn Diagram overlap may be over 90%.
Then I started thinking about applying this principle to my entire life. I asked myself, if I could live anyway I want with no financial considerations, what would that life look like? Here is the list I've come up with so far:
- 8-10 eight hour shifts per month in the ED.
- Never work after 1 am.
- Have 80% of evenings free for volunteer work, time with spouse and kids, or time to play on a sports team.
- Have 3/4 of holidays and weekend days off to spend with family.
- See fewer than 2 patients per hour.
- Time for one 2-4 day trip per month plus one 5-8 day trip per month.
- Four to six speaking gigs per year.
- WCI and writing time: 2 hours per day, four days per week, with one longer session of 4-8 hours per week except when on a trip.
- 4-6 days per month where I have 4-8 hours to play in the Wasatch- climbing, biking, skiing etc.
That's what the left side of my Venn Diagram looks like. Unfortunately, the right side currently looks like this:
- 15 eight hours shifts per month in the ED.
- Work after 1 am 7 days per month
- Have 70% of evenings free for volunteer work, time with spouse and kids, or time to play on a sports team
- Have 1/2 of holidays and weekend days off to spend with family.
- Seeing 1.5 patients per hour.
- Time for either one longer trip, two shorter, OR 4-8 days per month to play in the Wasatch.
- 6-8 speaking/consulting gigs per year.
- WCI and writing time: At least twice what I would ideally be spending.
So there is quite a bit of overlap (? 60%), but I can increase happiness and decrease burnout if I can increase the overlap. I'm taking a significant step this summer when I drop my 10pm-6 am shifts, going from 15 shifts a month to 12. The other step I'm working on is to do a better job limiting my WCI by being better at delegating and drawing better boundaries.
What do you think? What does your Venn Diagram look like? 80% overlap? 20% overlap? What steps can you take to increase the overlap? How have you drawn boundaries in your life? Comment below!
I take exception to the beginning of your article. I am a member of TeamHealth. My democratic group joined them just over a year ago. The process was not predatory in any way, shape or form. It has been a good move for our clinicians. TeamHealth also brought Dike in to speak to us about burnout. He and TeamHealth do a great job of trying to improve the lives of our docs.
If you think I hate TeamHealth, you should hear what I think about EmCare (who tried to steal my business.) I’m glad your experience was not predatory. I hope it works out in the long-term. There are now many areas of the country where an emergency physician cannot be a partner in a small democratic group because ALL of the hospital contracts in the area are controlled by EmCare, TeamHealth, or both.
Both companies are corporations, owned by shareholders. Those shareholders expect to make a profit. Where does that profit come from? It comes from the labor of emergency physicians. How do they boost that profit? Either by paying physicians less, creating efficiencies (you know, like getting those emergency physicians to see more patients), or by getting more contracts with hospitals, often taken from small democratic groups. Perhaps not in your case, but certainly in my case.
The usual tactic is to tell the hospital administration they will fix their hospitalist problem (the fact that you have to pay hospitalists more than they generate to get any) if they will give them the ED contract. So if the SDG wants to keep their contract, they end up having to subsidize the same hospitalists blocking their admissions.
http://www.staffingindustry.com/Research-Publications/Daily-News/Team-Health-Q1-net-revenue-rises-on-acquisitions-33970#sthash.fIGg8mER.dpuf
You may truly believe that the corporate practice of emergency medicine is good for physicians and patients, I don’t know. But if you do, I think you’re wrong. I think it is bad for both.
Nice press release, at least theyre laser focused on whats important, their finances and growth drivers, aka your prior profit margins.
Its crazy to think all that revenue is basically being skimmed off the tops of what would potentially be physicians income. Obviously, there is more than just your salary or there wouldnt be any profits left over for a company to grow at that clip. You dont have to be an entrepreneur or go after maximizing it, but its good to be aware of the possibilities and trade offs you’ve accepted.
And how do they continue to deliver profits to shareholders when there’s no more acquisitions to make…
Somebody needs FAAEM after their name…
You’re probably right. I’m actually surprised my group hasn’t switched their ACEP membership requirement to AAEM. I see benefits to both organizations.
Very interesting comments. I’m a recent residency Grad who is looking for a job where corporations have saturated all of the local EDs. I have offers from Team Health, EPMG, and EMP. Do you (or anyone else reading this) have a similar opinion of the latter two corporations? Both advertise themselves as democratic groups with profit sharing but I have trouble buying it. It’s frustrating not having a true democratic group as a job option.
I don’t know anyone who has had EPMG or EMP steal their business. I like EMP’s model better than EMCares or Team Healths, but you’re right it isn’t the same as a true democratic group. I don’t know EPMG as well.
E-mail [email protected] and ask to speak to a board member. We’ll talk to you about all the CMGs. (I’m a board member.)
i;m completely on board with WCI and the message here regarding burnout. Emp became usacs, basically a large merger with 7 other indep groups. my group has given me everything I requested (within reason) regarding burnout so I have no complaints at this point in time. I also know about team health and emcare. I definitely agree you should email AAEM, look on SDN =studentdoctornetwork.com, ask your alumni network and get the facts as every gig has its pros and cons.
Feel free to give me a shout on SDN, look for my name, msmentor018
The same is occurring in hospital-based radiology. The venture-funded based companies generate revenue off the backs of the employed radiologists. The hamster wheel spins a little faster very day. And the paycheck gets a little smaller.
If you “rarely see the same pt twice” as an ED physician, you’re definitely not working many shifts, (at least at a tertiary academic center)
Everyone has their frequent fliers. Perhaps we have fewer than most, I don’t know. But I bet I only see a patient I’ve personally seen before a couple of times a month.
I get a feeling from several of your recent posts that you are definitely transitioning your involvement with WCI — going from blood/sweat/tears active labor to implementing autopilot features where possible. probably due to a combination of seeing financial independence on the horizon, simply not having bandwidth to personally keep up with the needs of the huge following you have built, and maybe feeling the itch to take on a different challenge (total guess).
I have mixed feelings because you totally deserve whatever you decide to do, but it’s also sad for all of us still in the trenches of a terrible healthcare climate to not have the same “kindred spirit” from 2011-2013 intimately involved and helping us along. This is not meant to be mean-spirited because again you have helped me and thousands more in immeasurable ways.
I’m actually spending more time than ever on WCI and will be reducing shifts next summer at work so I quit shortchanging my family and personal time.
But in order to reach more people, I do have to implement efficiencies whenever possible. The forum, for instance, allows readers to answer each other’s questions. I also contract with someone to sell the ads so I can spend time directly interacting with readers. She’s better at keeping it all straight than I was anyway.
I have seen Dike Drummond speak at one of those corporate retreats. Mine was through the company I work for, TeamHealth. I have also read his book and found his advice very valuable.
Here is my list of items I took away from Dike:
1) My wife and I implemented date night once a week which we place in the calendar. It allows us to enjoy ourselves and just so no whenever work needs to take up that evening.
2) I have decreased my shifts.
3) With more free time I now have more time to exercise and eat healthy.
Having increased financial security due to living well below my means made the above three easy to accomplish. I am now not that interested in early retirement and see myself working many more years to come.
With increasing financial security I will keep cutting shifts so that I am working no more than 2 days a week with no nights. That is my goal.
I also must address the comment above about the “evil” corporate guys. I currently work for TeamHealth and have worked for an independent group in the past. Each has their pros and cons. Although I agree that when working for TeamHealth I am working for a faceless conglomerate that makes decisions without ever stepping foot at your hospital. Any requested take a long time to accomplish since it must go through layers of corporate beurocracy which is extremely frustrating. But there are some benefits as well:
1) TeamHealth gets to negotiate with insurances on a larger scale and therefor increases reimbursement. We are some of the highest paid docs in the area.
2) If staffing is low they send a few docs from out of town to help fill shifts instead of forcing the active staff to work more than they are comfortable with.
3) TeamHealth does all the billing, coding, and insurance chasing to get paid. For a doc, all you do is come in to work and see patients. Once a month you get a check for the work you did.
Basically working for a Mega Corp is easier than the democratic group. As well as possibly being more lucrative. In return you give up some autonomy and decision making.
That autonomy becomes more and more important to me each year. I don’t mind people choosing to go work for a corporate emergency medicine group. I do mind when someone has no choice but to work for one if they want to live in any given area. I also have a problem with their predatory practices.
I believe in the long run that both doctors and patients do better when the doctors control their business.
Obviously, the bigger your group the better negotiation you have with insurers. But there are other options besides selling out to a CMG. For instance, you can band together with other SDGs for your benefits and insurance negotiations.
Maybe it works out better for a majority of practices because most physicians simply arent that great at business, and its really hard to do both well given they both need a considerable amount of time to do well.
Listening to my friends old practice (which he left to start his own) blunders in their finance and governance would be hysterical if not so awful, Im guessing this is more the norm than the exception. It would be so helpful for medical schools to have some mandatory basic finance and business courses.
I strongly agree with having good boundaries. I work hard when I’m at the office, but when I walk out the door–I’m done. I was told that it is possible (and easy) to get remote access to the EMR from home…yeah, I don’t think so. That’s why we have docs on call, to handle issues after hours.
I’m a visual person, so I definitely like the idea of using a Venn diagram to conceptualize ideal vs actual practice/life. I think I’m probably in the 50% range. I really like my primary job, it has very reasonable hours, infrequent call (like 2-3 times a year), great benefits, and opportunities to teach. And if it was just my primary job, I’d probably be over 60%. If I add in the moonlighting, it brings me down a bit because I take 3-5 shifts per month, which is time I could be spending doing something fun. It’s not all bad–I like the extra income which I put towards retirement (and having fun too), the tax benefits of 1099 income are great, and it keeps up my acute psych skills–but it’s still extra work. Ideally, I’d just have my primary job, work 4 days a week (or less, trust me, I’d be okay with less), and spend the rest of my time enjoying life–friends, family, traveling the world, being outdoors, reading for fun (not medicine).
For me, increasing the overlap would likely require scaling back on the moonlighting. I’ve already done that to an extent (I still remember a month when I took 12 shifts on top of my regular job…not fun). As my salary has gone up on my primary job, I’ve cut back on shifts, with no effect on my income. The only problem is that I can only cut back so much before it’s no longer worth it (overhead of moonlighting insurance); and if I completely stop, I can’t contribute to my solo-401k, and lose lots of nice tax deductions.
So either I need to get creative and come up with an idea that once up and running can generate passive income, or I keep working/saving until my investments generate that income, and hope I don’t burn out before that happens.
Interestingly, there has been a greater effort recently amongst residencies to address physician wellness–starting with defining it as something other than just “lack of burnout”, helping residents create a better life/work balance, etc. Probably helps to start early…
As a resident, I wouldn’t even know where to start drawing my diagram.
Of course I realize that I’m not the target audience for this post, but it’s still a funny reminder of just how bizarre my work/life balance is right now.
I hope that you’ll reconsider including yourself in the target audience.
Keep reading this blog (among others), and don’t fall into the traps that many of us do after leaving the shelter of residency. Try to foresee the life you want in the future, and don’t dig a hole out of which you’ll labor to free yourself, potentially burning out in the process.
While it may feel like you’re just slave labor as a resident, there are actually attendings who enjoy teaching, and who sacrifice their productivity to do so. I can look back fondly at residency because most of my attendings cared about my success without regard to their personal monetary interests.
Just wait till you join (if you do) the fairly typical private practice that “eats its young.” Signing bonuses and income guarantees are transient lures. The patients may need your medical skills to help them, but the practices and hospitals (your masters) will view you as an investment. As such you are there to earn the best returns possible…for them. Be very careful whom you trust.
On the dental side we have similar corporations buying up small practices. They usually will pay 50% more than the typical office would have gone for, so it’s hard to say no to them. But, then they hire new grads and pay them 25% of collections, normal is about 30%, and tell them it’s just a 5% pay difference….how about that math huh! Most of the kids I see come out now have so much debt they think the only thing to do is work for the corporation at least for a year or two and I see this burnout happening quickly.
I know there are pros and cons, but I’m WCI in that patients benefit when the doctors run their practices. No one is looking over the dentist shoulder telling them to find another cavity to fill. I just hope I feel the same when it’s time to sell, that 50% premium is what they steal your soul with! 😉
I was at a presentation by Dr. Drummond as well, and it was very valuable for me. Separating work and home is difficult as a primary care, rural doctor where my phone is always on and call never ends. I did make some adjustments to protect my home life after the talk.
Two of the most important changes I did make have made a big difference. The first was to improve my computer/documentation skills. He made the point that you should find the person who does the best job of being efficient with the EHR and emulate them. You’ll always have to deal with the EHR, and so “quit complaining about it and get good at it.” To have command of the EHR improves the quality of life at work and at home, and I’ve become more of a master of using Dragon and commands since that presentation.
The second change was really a result of a conversation I had with my partner several years ago. He said that you need to spend the last 10 years of your work life practicing the way you want and enjoying what you do. Dr. Drummond’s presentation reminded me of that, and I’ve made changes to be able to work in that way.
I’m on board with WCI’s ideas of fighting burnout by living below your means and working toward financial independence. Your perspective changes when the workdays become optional.
When I try to visualize the “perfect practice / life” it’s easy to say I’d like to work less, sleep more, etc… But dropping shifts and responsibilities would also drop income, delaying by some years my ability to reach financial goals that I’ve made.
I may find out that I’m wrong someday, but I don’t think my “Perfect Life” includes maintenance of certification, ACLS and PALS classes, and 3 a.m. labor epidurals. I think all the work-related activities will be in that other circle. I enjoy certain aspects of my workday, but I like my days off better. My work / life balance is pretty good for a hospital based anesthesiologist, so I’m going to keep working full time towards an early retirement (where the balance will be all life and no work!)
Less than 2 patients per hour, 40,000 patient visits by 40?! Wow! No wonder I felt the need to retire at 53. On the brighter side, I guess the extra patients helped fund the early retirement. Glad I had LBYMs drummed into me by my parents. I think I’ll read the book.
And FWIW, I agree with WCI on physician independence and corporate management.
My burnout is in response to quality metrics. I am now at risk for compensation decreases if too many patients for whom I am listed PCP use tobacco, don’t get recommended diabetes tests, or don’t get recommended mammograms, etc. I don’t like the frustration I feel with patients when they aren’t “compliant”–when I feel that is rightly their decision.
Five years ago I planned on working till 65 years old. Now I’m planning to retire in one year, at 60. I will miss the good parts, but not that frustration. I am quite happy that I saved enough to be able to afford the change in plans!
It is difficult and continual process to find that work-life balance that we all strive for, and it seems like we all have a different definition of what exactly that looks like. Taking the path of medicine, I have comes to terms with the fact that more likely than not my life will always be quite busy, and i’ve noticed that because at baseline I am always busy it doesn’t feel quite right when you aren’t. So personally, I try to incorporate more of the activities that make it make more of a balance or shift me to the left side of the Ven diagram by doing the things I enjoy more frequently but maybe at shorter time intervals i.e like it would be great to get to the gym and exercise for an hour, but instead just getting in there for even 15 mins to 20 mins and hitting a couple exercises, i’ve found makes a big difference.
For me.. life was put into perspective with the loss of my younger brother 2 years ago when he was just 32. Im sure we all deal with death and dying with what most of us do in our daily practice but when this happens so close to home… it completely changes your perspective. I was 35 heavily focused on my career without a lot of effort placed in the other areas but made some significant changes since that time. I like Zig Ziglar’s Wheel of Life which had forced me to think about the areas other than career and finances:
Family – expanded family (aiming for 4th kid this year), date night with the wife, lots of family vacations!
Spiritual – this is hard one for me… i’ll keep this one personal.
Intellectual – wife and I are aiming for one book a month with at least half being nonfiction
Physical – accountability with my wife.. I went from 205lb to now 190lb… lots of veggies and meats. Wife hates me..
Social – normally would prefer to stay home after a long work week… now must go out with friends 2-4/month
Career – set reasonable goals/objectives, simple motto of.. take care of some folks, teach/learn, go home
Finances – with the help of Dave and WCI.. this is really on autopilot now. Well on our way to consider retirement at 55-60… but I don’t think I will… perhaps just work a bit less? I really enjoy what I do… great clinic, staff, pts, call, teaching, and work environment.
Hope this helps motivate!
Beautiful comment. Thanks! Sorry for your loss. When my husband had his stoke, it was also a life altering experience for us. I remember lying with him in the ICU so filled with gratitude for the awesome life we have together. I didn’t regret all the time we hadn’t spent with kids, family, and friends because we had. Money only entered our thoughts because we were thankful for the emergency fund we had built. Each of us must strive for our personal balance. Best wishes.
I like the venn diagram idea and I’m going to steal it 😉 I actually treat several physicians who are dealing with burn out and I think this is a nice visualization to get people moving away from black and white thinking, like they must quit medicine, to thinking about real changes they can make in their life right now to be happier.
I think I just have one circle, or at least close-90% overlap? I currently work 23 pt hours a week, between the hours of 9AM-2PM. In my ideal world I’d work 10AM-2PM, 4-5 days a week. But since I have to be up at 7:30 anyway to get the kid to school, I might as well be at work at 9. So in 10 years I will probably cut back to those hours. But I don’t want to retire, I would go stir crazy. I take 2 weeks off a Christmas every year while my son is on his school break and by the end of it, I am so ancy and restless and ready to get back into my regular routine that I’m happy to go back to work. I need to be productive to be happy, I don’t do well with so much time on my hands.
As for boundaries, I work such a reasonable amount, that I’m totally OK blurring them. I really don’t mind sitting in bed for 30 minutes to answer patient calls, emails, refills, etc while my son is playing downstairs with the neighborhood kids. When I was in residency I had to have very strict boundaries because if I did work at home I really resented my patients. But now since I have so much more time, I’m much more willing to share it. That said, I don’t like charting at home, so I’m very vigilant about finishing my notes before I leave the office at 2:30 every day.
Wife, mother, sister, daughter, pediatrician. I found it exhausting trying to keep them all separate. Like you, I am happy blurring their lines. Each making the other better. Enjoy your comments very much! Best wishes for continued success and happiness.
Thank you! I always enjoy the things that you share!
I think Dike’s website and book are a great starting point for any physician going through burnout. There is a lot of very simple and actionable information that is quite effective. It is a useful site even if you are not burned out, as there are many really good ideas there that anyone can use – not just the burned out.
I think ideally fighting burnout from all angles is wise. Achieving early FI is smart because it gives you so many options like quitting, going part time or radically changing your practice. But preventing burnout with boundaries, mindfulness and various efficiency and workflow strategies that Dike talks about is the other side of the coin. Good stuff.
Important topic in our family. Husband was burnt out in military med; left it and medicine 4 years ago. Had they returned him to research not mass production clinical care he might still be happily working, or see he would like a return. I burnt out overworked in VA system when workload doubled with retirements of other docs. Working on maintaining credentials more than return to work as I had known it, as a back up plan for financial security/ sanity related to having options if retirement gets boring.
Sad thing for me is husband sees no reason/way to do medicine in a satisfying, non harmful way- it’s as if he assimilated my issues at VA with his own. He voices concerns that he’ll get sued after an unblemished few decades if he sees even one more patient, and has taken a low wage ‘locums’ job in an area he enjoys (Best Buy computers) with satisfactory control hours and days worked.
Family finance manager, me, is unhappy he spends 10-20 hours/week earning $7K/year when he could spend 10-20 hrs/mo earning $20K/year. And is losing option to be able to get $200K/yr if that were ever important to us again. But I’m also considering emulating him, though in a bakery or pet shop not computer sales.
And most importantly, though of course if it weren’t true America would have two more full time doctors caring for people now, thank goodness for the principles WCI lays out and which I’ve been following since I first picked up Andrew Tobias’s The Only Investment Guide You’ll Ever Need. WCI has reinforced and finetuned our financial plans and decisions which enabled our easy fix for burn out.
I have heard Dike speak also, I think he’s a great speaker and had a lot of good ideas. But it’s hard for me to believe a guy who burnt out and no longer practices medicine (and seems very happy with his new life) sell me on how not to get burnt out.
I know that it one of the major reasons this site is so successful, knowing you are in the trenches with us 🙂 in addition to be devoted to the mission of providing docs with some financial education
A few of my partners felt the same way about Dike and his career change. Personally, I think changing to a new career (or retiring early) are perfectly viable burnout solutions. Do what makes you happy!
I hope I don’t lose too much credibility going to 3/4 time this summer, but I can’t keep up this pace and certainly don’t need the income. I didn’t go into EM because I wanted to work 80 hours a week at two jobs and I’ve got too many hobbies to spend my whole life working, even if I like the work.
As painful as a busy 12 hour shift can be, I’ve found that being able to work less total days a month is better than working shorter shifts and having to go in more frequently. I now only work ten, 12 hr shifts and think I’ve hit the “sweet spot”. I’ve also picked up some teaching time at the local medical school which is surprisingly well compensated and enjoyable. Being debt free and working towards financial independence also helps.